Wiki Medicare Plan Denying Screening Colonoscopy

[bonnienorth55]

Hello, I am stumped on some denials we've been getting recently when billing CPT 45378 for a screening colonoscopy. The claim I'm working right was billed with dx Z12.11 and CPT 45378 to a United Healthcare Medicare plan. We got that CPT with that dx authorized. They are denying for "medical necessity" with LCD L36868. We've billed this screening colonoscopy code in the past with just the Z12.11 dx when no abnormalities are found/no family or personal hx/no biopsies taken and they've always paid. I'm confused why they would authorize this procedure and dx pairing but then deny for medical necessity... I can't seem to find any new information on whether something has changed as far as billing a screening colonoscopy when no biopsies are taken. Thank you in advance for any feedback!

 

[xXxPARAGONxXx]

Hello, I am stumped on some denials we've been getting recently when billing CPT 45378 for a screening colonoscopy. The claim I'm working right was billed with dx Z12.11 and CPT 45378 to a United Healthcare Medicare plan. We got that CPT with that dx authorized. They are denying for "medical necessity" with LCD L36868. We've billed this screening colonoscopy code in the past with just the Z12.11 dx when no abnormalities are found/no family or personal hx/no biopsies taken and they've always paid. I'm confused why they would authorize this procedure and dx pairing but then deny for medical necessity... I can't seem to find any new information on whether something has changed as far as billing a screening colonoscopy when no biopsies are taken. Thank you in advance for any feedback!

Doesn’t necessarily mean that you were billing right. It just means the claim was paid. UHC may have changed an internal policy or began auditing certain claims. Now it is denying what should have always been denied.

CPT 45378 is for a diagnostic colonoscopy; it is even stated in the code description:

Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

They cited LCD L36868 because LCD L36868 applies to a “Diagnostic and Therapeutic Colonoscopy.”

But, Z12.11 applies to a screening colonoscopy. That is why it was denied for medical necessity. Z12.11 does not support the medical necessity of a diagnostic colonoscopy.

In order to bill a diagnostic colonoscopy, the patient needs to be symptomatic. If the patient is not symptomatic, then you cannot bill for CPT 45378. You must bill for a screening colonoscopy.

Medicare uses HCPCS Level II G0121 for a screening colonoscopy (on a patient who is not high-risk).

Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

(G0105 is for a screening colonoscopy on an individual at high risk.)

If for some reason UHC Medicare does not accept G0121, then you would bill CPT 45378 with modifier -33.

 

[bonnienorth55]

CPT 45378 is for a diagnostic colonoscopy; it is even stated in the code description:



They cited LCD L36868 because LCD L36868 applies to a “Diagnostic and Therapeutic Colonoscopy.”

But, Z12.11 applies to a screening colonoscopy. That is why it was denied for medical necessity. In order to bill a diagnostic colonoscopy, the patient needs to be symptomatic. If the patient is not symptomatic, then you cannot bill for CPT 45378. You must bill for a screening colonoscopy.

Medicare uses HCPCS Level II G0121 for a screening colonoscopy (on a patient who is not high-risk).



(G0105 is for a screening colonoscopy on an individual at high risk.)

If for some reason UHC Medicare does not accept G0121, then you would bill CPT 45378 with modifier -33.

Thank you for your response! We tried billing a corrected claim using the G0121 code and they denied for no prior auth then we tried the 45378-33 and still denying for LCD issue :/ Seeming like we might need to appeal the G0121 since no biopsies were taken so we can't use the 45380 that was pre-authed...